23331 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
HulkHRg Project Identlflcauun PERMITNO.
Bui 4-4101
cv S r�a�,��s 2 3 3 31
me: one: APPLICAITON SUBMIIIAL
OR:e( CITY OF CUPERTINO-13UILDING DIVISION
Canlrad.�s Name: see.N.: APPLICATION / PERMIT
BUfLDINGELECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROL N
Architect/Engicassn LR.No:
L' ' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: _7 GJ r JN PERh9TI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IFerem that lam licensed underprovisions oeAPPLIANCES RESIDENTUL JOB DPSRIDON
IngwlthSoctI..700)ofDlvislon3 ofthe BuslnessandlmfeadonsCode,andmy
limnseisln(uRf deffect. �1 PANELS ats
LicenseC m LIc.N 60� 5kms{1.; {E ,
Date C2 Contra d h// L UP TO 2DOAMPSa
ARCHITECT'S DECLARATION 201-1000AMPS
gy�pp++as 7. I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
hi Licensed Professional SICNSELECTRICAL A L E D
<6 OWNER-BNWER DECLARATION M P T E
G SPEC AL CI CNT/MISC
7L, owingrason. Sullam31.5,B fromlheContractor'ssconce Any fm the
�p qqqqfollowingrem.n.iresitp7811.5,Business and Professions Code:Anycity or
Zt"u( county which requlresa permit tomrowct,alters Improve,demolbh,orrepelr TEMP.METQi DR POLE INST. nae `�`j 4 /y
t,`a 3 anystmctum pectic,Its issuance,sterequlresthe applicant forsuch permit to �yyCR DEVICES DA y • 2, 1
€5 O S file a signed statement that he U Ilmnsed pursuant to the provisions of the
G67 u,Tt., ContraRole LicemeLaw(Clupter9(mmrrentlngwith Section 9000)o(Dlvl- SWB.1MING POOL ELECTRIC VALUb71
HBO"J e.n3 of the Business and Prolessl..Code)or the he b exempttherefromand GG/
fS Q..••7777 the heels for the alleged exemption. Any violation of Section 78)13 by any OUTLE.ISSWITCHES-FIXTURES
06
applicant fora permit subjectsthe applicant to a civil penalty of nor rrore than
�j
five hundredI,asowner of ars
pro SQFT. STORIES TYPCCONSIRUCTION
r4,Cd NEW RESIDENTIAL ELI:CTR
�L as owner of the property,or my employees with weed as[herr sole
roto Ckc. 0Kion,will B..tr the work and the om Code;
The
not Intended or offend for
D doe(not apply
p ly to alnowe r f property
Co builds Contractors License Law
$
doesnot
suclytoanowner o(p through
Newest
emorlmprwvidedes that such
OCC.GROUP HIS.UNRS
who dodeuchworkhlmmEorthrwgh Msownemploym,provided thatsuch --
Improvements are not intended oroff mcd forsale.If,however,thebuilding or TOTAL:
Improvement build w(thinoneyearofcompldi.glheowner-builderwlll have
tlLLILurden of proving thathe did not build or improve for purpose of I..). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Ll L as or of the property,am exclusively contracting with Ilmnud PERMIT ISSUANCE
contractors to mrotsuct the project(Sec.7014,Business and Professbru Code:
The erty Contractor's License Law does not apply to an owner of propwho ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who centrads, for such p{ojects with a FEE SUMMARY
do a)licensed pursuant to the Contractor's License Law, BACK FLOW I'ROTFLT.DEVICE
L�I am exempt under Sec. B&P C for this reason '"OUTSIDE
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEIP17NN
WORKMAN COMPENSATION DECLARATION p'IXTUPF.S PER TRAP SCHOOL TAK Y N
❑I he affirm that I have o certificate of consent to opythare,ora RECEIPT N
39M0I te hof Worken'Comperwtlonituunnco oramrtl(led copy thereof(Sec. GAS FA.SYSTEM-11NCAOUTLETS PARKFEE Y N
3800.Tub C.) ^GS q RECEIPT If
PoIIryN eaao / GAS EA.SYSTEM-OVER4(EA)
Co���mpppany T tisBUILDING DI VISION PCIS
LHI�Certified copy is filedwereby th the cid. GRFASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b Bled with 1M city Inspection division.
CERTIFICATE OF EKCMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM P.A.200FT. Date Recei tN
(Thlssedion need rad be completed if the permit b forone hundred dollars
(f110).rle
I a.o h that In the performance work(orwhich this permit le belied, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person In any manner ao as to became subject to the WATER SYSTEM/TRrATING
Worker'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL ELMS. SQ.Fr. Date Remi til
Z 0 NOIICETO APPLICANT.-
after rruldng this Certalute.(Evemptlon,you
P:CC
should become subject to the Workers''Compemetlon provisions of the Labor TOTAL:
N Coleyot at forthwith comply withsuch peovbbrumthis permit shall be mB �r
ME
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G
I hereby'(firm that there b a mnumdion lending agency for the perform- ELECTRIC FEE
D Z ance of the workfor which this permit b issued&c.3097,Civ.C.) TOTAL:
U O Leeler.Name PLUMBING FEE
LL H Lender's Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertitythatl havercadthisappBcatlonand statethe the above information
4 Is to comply with alldtyand muntyordinanwand state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby auth.dze representatives of this
F Z city to enter upon the ab.vcmemmnrd property for lmpection purposes. ALTER OR ADD TO MECH. Date Recei [M
— (We)agree to cove,Indemnify an d keep harmless the City of Cupertino
a Herat Babllitles,pdgments,c.wsand expenses which may In anywayaccrue AIRHANDLINGUNIT(TO10,000CFM) SUBTOTAL:
aga/rr�/ ,I/tl�C�ity In s o(the granting of this permit.
//sT C/^- c�/r�ll9 a AIR HANDLING UNIT(OVER 10,WO C£M) CONSTRUCTION TAX
Signature of Applicant/Contractor Date E%HAUSTHCOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tN
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
1{ralth and Safely Code SMIon 25532(a)I HEATING UNIT(OVER 100,001)BTU) TOTAL'Iij so:
�❑ Yes M No
Illthczppllnnt.rtulurebuiiding.ccvpantumcgtilime tord.vi. VENTILATION FAN(SINGLE RFSID) FWNVDATE
which emit hazard...air contaminants as dented by the Bay Area Air
Quality Management District? BOI.ER-COMP DHPOR 100,000 BTU)
,-.[ 1Yro gNo 20 0
ave read lealthhe a at mode,le tions,255DS, SS33 undeand 255 4. 1 of BOILER-COMP(OVERIOB,IXq BPM pCp
the Californiaandtat if the
building
Code, of mmntlyh have
at and that 1 IBI`61�
retporunderbilityton notify
the occupant not errcuireme t$tenant.that It mets my NEW RESIDENTIAL MECH. SQ.Ff
pdortobuat.afa theoccupantoftherequlremenleWhich must be met 611a V� `VJ+[,T11[IVU
prior to Lmuance o(a Certifkate ofOmpanry. H
Owner or authorlad agent Date TOTAL: ISSUED BY.. A
1 i
OFFICE COPY